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Health Screening
Patient Name
DI #
Emergency Contact Name
Emergency Contact Phone
1. Are you under the care of a medical doctor at this time?
Yes
No
Physician’s Name
Physician’s Phone
2. Have you been treated by a medical doctor or been in the hospital in the past six months?
Yes
No
3. Are you allergic to any medications, drugs, or latex materials?
Yes
No
Indicate Allergy List Below
4. Do you have or have you had any of the following diseases or problems? (If ‘YES’, please give brief explanation)
a. Artificial heart valve
Yes
No
Details:
b. Any heart condition
Yes
No
Details:
c. High blood pressure
Yes
No
Details:
d. Joint Replacement/Prosthesis
Yes
No
Details:
e. Have you ever been told to take antibiotic premedication before a dental visit?
Yes
No
Details:
V
Yes
No
Details:
g. Stroke/TIA
Yes
No
Details:
h. History of cancer or cancer treatment
Yes
No
Details:
i. Tuberculosis
Yes
No
Details:
j. Glaucoma
Yes
No
Details:
k. Hepatitis
Yes
No
Details:
l. Kidney or renal disease
Yes
No
Details:
m. Lung or respiratory condition
Yes
No
Details:
n. Asthma (breathing problems)
Yes
No
Details:
o. Cold sores or ‘fever blisters’
Yes
No
Details:
p. Depression
Yes
No
Details:
q. Epilepsy/Seizures
Yes
No
Details:
r. HIV
Yes
No
Details:
s. Prolonged bleeding
Yes
No
Details:
t. Thyroid conditions
Yes
No
Details:
u. Arthritis
Yes
No
Details:
5. Are you taking any of the following drugs or medications now or in the past 6 months:
a. Antibiotics
Yes
No
g. Steroids or cortisone
Yes
No
b. High blood pressure medication
Yes
No
h. Antidepressants
Yes
No
c. Anticoagulants (blood thinners)
Yes
No
i. Insulin or anti-diabetic
Yes
No
d. Heart medication
Yes
No
j. Aspirin
Yes
No
e. Birth control pills / HRT
Yes
No
k. Herbs or natural medicines
Yes
No
f. Vitamins (over the counter or RX)
Yes
No
l. Other medications
Yes
No
Additional Questions
6. Have you now or in the past year used alcohol, tobacco products, or drugs?
Yes
No
7. Have you now or in the past year used self-prescribed medications or drugs?
Yes
No
8. Do you have any disability (physical, mental or developmental) we should be aware of to provide appropriate treatment for you?
Yes
No
9. Do you have any disease, condition or problem not listed above?
Yes
No
Details:
10. Are you pregnant?
Yes
No
Due Date:
Dental Questions:
11. Are you having any gum/head/neck pain or discomfort?
Yes
No
12. When was your last dental visit?
Under 6 Months
Over 6 Months
Date:
13. Local anesthesia or nitrous oxide may be indicated for completion of your dental hygiene treatment.
Yes
No
I consent to the use of local anesthesia
Yes
No
I consent to the use of nitrous oxide
Yes
No
Typed Patient Name
Patient Signature
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